THE IMPACT OF A BEREAVEMENT INTERVENTION ON LEVELS OF GRIEF IN PREGNANT WOMEN WHO EXPERIENCE PRE-TWENTY WEEK LOSS Proof of Life Protocol: Pre-Twenty Week.

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THE IMPACT OF A BEREAVEMENT INTERVENTION ON LEVELS OF GRIEF IN PREGNANT WOMEN WHO EXPERIENCE PRE-TWENTY WEEK LOSSProof of Life Protocol: Pre-Twenty Week Loss and GriefPresented by: OLINDA PRUITT JOHNSON, PhD. RNC, CNSPRE-TWENTY WEEK LOSS AND GRIEF1The purpose of this research study was to evaluate the impact of implementing a bereavement intervention on levels of grief in women experiencing perinatal loss between the gestational ages of 12 to 19 weeks, and 6 days (or a fetus weighing less than 500 grams) compared to women who receive the usual standard of care following a perinatal loss Statement of the ProblemPRE-TWENTY WEEK LOSS AND GRIEFPRE-TWENTY WEEK LOSS AND GRIEFBackgroundOne in six pregnancies are lost before the 20th weekLosses can be devastating for woman and familySociety considers perinatal death a private affair ; actual impact goes underreported or under recognized12-31% of all conceptions terminate in early or late fetal death Craven and Wise(2000)Abma & Henshaw (1999) reported a rate of spontaneous abortions (unplanned and unexpected) about 16%Regardless of gestational age the loss of a pregnancy can be devastating and is associated with some level of grief, anxiety and or depression

PRE-TWENTY WEEK LOSS AND GRIEF

BackgroundOver the last thirty years there has been remarkable improvements in caring for a loss greater that twenty weeks or over 500gmsThe care of perinatal loss under twenty weeks is focus on physical needs and minimal emotional or psychological interventions are providedMost care is provided in isolated ERsFollow up in Gyn Clinics verses Postpartum clinics

PRE-TWENTY WEEK LOSS AND GRIEF A randomized controlled trial was conducted utilizing a two group posttest only design. N=40Research DesignPRE-TWENTY WEEK LOSS AND GRIEFFor the purpose of this study,the Neuman System Model was utilized as the conceptual framework for women experiencing perinatal loss under twenty weeks gestationTheoretical FrameworkBetty Neuman Model

PRE-TWENTY WEEK LOSS AND GRIEFBetty Neuman Model (Grief is More Than Tears p.79)7PRE-TWENTY WEEK LOSS AND GRIEFTheoretical FrameworkThe NSM model provides a solid theoretical foundation for this study.

The primary stressor is perinatal loss.

This perinatal loss causes a disruption in the FLD which are unable to contain the stress reaction which leads to a disruption in the clients NLD. As a result, she is no longer in a homeostatic state and physical and psychological reactions to the perinatal loss (grief) are evident.

The lines of resistance are activated to protect the client and at this point a secondary level of intervention is required to return her to a steady state. The clients ability to stop the reaction and return to homeostasis is dependent on her support systems and core resources as well as appropriate health care intervention.The use of a prescribed evidence-based, secondary nursing intervention should mitigate the degree of reaction (grief) to a stressor (early perinatal loss) and return or reconstitute the individual system to a stable state. PRE-TWENTY WEEK LOSS AND GRIEFDo women who experience early perinatal loss (12-20 weeks or less than 500 grams of fetal weight) and seek care at a county funded hospital and receive a perinatal bereavement intervention in the ER demonstrate decreased levels of perinatal grief at their two-week follow-up appointment, as compared to those women who are in the attention control group?Research Question/Hypothesis

Subject acquisition, consent obtainmentand data collection occurred on the 2ndfloor of the Obstetrical Emergency Center (OBEC)of Lyndon B. Johnson General Hospital, a county facility. The OBEC provides care for over 1,500 women with pregnancy complaints per month. One-third (500) are admitted to Labor and Delivery from the OBEC and an estimated forty (40) women per month are treated for pregnancy loss under twenty weeks in the OBEC.

The follow-up visit occurred in a private exam room in the Obstetric-Gynecology (Ob-Gyn) Clinic on the 2nd floor. SettingPRE-TWENTY WEEK LOSS AND GRIEF

The population of study were women experiencing pre-twenty week loss in a county obstetrical emergency center. The sample of 40 women, were divided evenly into an experimental and a control group, for this study. The sample size, for this study was based on an effect size of .57 using a power of .8 and an alpha of .05 for an independent students t-test (Cohen,1965). The effect size was determined from two meta-analysis studies that evaluated educational interventions for improvement of patient care (Driel & Keijser, 1995; Theis & Johnson 1995). These meta-analytical studies reported effect sizes that ranged from 0.46-0.57 for primary prevention and patient education.SamplePRE-TWENTY WEEK LOSS AND GRIEFPRE-TWENTY WEEK LOSS AND GRIEFTable 1Frequencies of Selected Demographic Characteristics broken down by group

VariablesTotal (n=40)Experimental (n=20)Control (n=20)F%F%F%Language Spoken English2562.514701155 Spanish1537.5 630 945Race/Ethnicity Hispanic/Latino2152.510501155 African-American 922.5 525 420 White/Angelo 717.5 420 315 Other 37.5 15 210Marital Status Single1537.5 735 840 Living Together1127.5 525 630 Married 717.5 315 420 Separated 512.5 210 00PRE-TWENTY WEEK LOSS AND GRIEFVariableMSDExperimentalMSDControlMSDAge in years27 (7) 28.8 (7.3) 25(6.1) Income20,240(9,494.72) 23,111.00 (10,916.00)20,916.00 (8,310.60) Pregnancies 3.5 (1.9) 3.8 ( 2.2) 3.2 (1.3) Living children 2.2 (2.0) 2.6 (2.6) 1.8 9.5)Table ??What is this a table of? (Enter description here)

PRE-TWENTY WEEK LOSS AND GRIEFVariablesTotalN=40%ExN=20%ControlN=20%EducationElementary thru 8th16 40 945 735High School16 40 6301050College8 20 525 315Health InsuranceNone1537.5 630 945Table ??What is this a table of? (Enter description here)

InstrumentsPerinatal Grief Scale(measures grief in women who experience loss)Translated 22 languages33 ItemsTotal Score 0f 33-165Higher score =more griefAlpha = .96Lasker& Toedter (1989)

Our StudyAlpha =.96Homogenous groupsPRE-TWENTY WEEK LOSS AND GRIEF

PRE-TWENTY WEEK LOSS AND GRIEFBereavement InterventionMedical Professional Guidelines: Providing care for the family experiencing perinatal loss, neonatal death ,SIDS or other Infant deaths. (Not used in previous research)

Follow-up telephone call 1 week after loss.

1. Evaluate clients level of need.2.Offer and encourage discussion of pregnancy and loss experience.3. Notify chaplain regardless of gestational age4. Naming ceremony5. Baptize (if possible)6. Memory box : Review contents with family Includes list of support web sites.7. Note pad for writing a letter to the unborn8. Self address envelope

PRE-TWENTY WEEK LOSS AND GRIEFMEMORY BOX CONTENTSBLANKET/SMALL GOWNCAMERASTUFF ANNIMALBRACELETS DATE /TIMECopy of Lab(Beta HcG)Bereavement ProtocolPRE-TWENTY WEEK LOSS AND GRIEFTreatment of DataData was be analyzed using the Statistical Package for the Social Sciences 15.0 (SPSS) Data from the demographic questionnaire was analyzed using descriptive statistics of frequencies and percentages with means and standard deviations being calculated for all interval and ratio level data.

A Students t-test for independent groups was used to answer the research question: whether exposure to a bereavement intervention would have impact levels of grief (total score on PGS: (33-165) in pregnant women who experience pre- twenty week loss. Higher score the greater the grief.ResultsTotal PGS scores indicated no significant differences between the two groups on overall levels of grieving (t=2.518 p=.065)

Examination of 3 subsets of the grieving process reveals no differences in the active grief processes or coping processes for the 2 groupsThere were significant differences in the levels of despair between the 2 groups (t=38 p=.000)Despair, is complex form of grieving that is seen when coping mechanisms fail to ameliorate the grief reactionThe experimental group displayed significant lower levels of despair PRE-TWENTY WEEK LOSS AND GRIEFAnalysis of the total PGS scores showed no significant differences between the two groups on overall levels of grieving (t=2.518 p=.065)Examination of 3 subsets of the grieving process reveals no differences in the active grief processes or coping processes for the 2 groupsThis was attributed in part to the short 2 weeks of time between the intervention and the measurement of griefHowever, there were significant differences in the levels of despair between the 2 groups (t=38 p=.000)Despair, is complex form of grieving that is seen when coping mechanisms fail to ameliorate the grief reactionThe experimental group displayed significant lower levels of despair

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PRE-TWENTY WEEK LOSS AND GRIEFConclusionThe study concluded that the bereavement intervention was effective in ameliorating the degree of the grief reaction as measured by levels of despair in low income, women experiencing an early pregnancy loss.PRE-TWENTY WEEK LOSS AND GRIEFUtilization of a bereavement intervention on all women experiencing loss regardless of gestational age

Inclusion of the women in decision making on what level of care is needed to help them resolve grief after loss

A bereavement assessment has been added to the screening tool in the electronic medical record at the institutionImpact on Clinical PracticePRE-TWENTY WEEK LOSS AND GRIEFThis study needs to be replicated using a larger and more diverse sample of women including those with varying socioeconomic status receiving care at private as well as public institutions.

Future studies need to measure grief at several points after the pregnancy loss to better explore the grief process over time and to examine the relationships between active grief, coping, and despair. Future StudiesProof of LifeFollow up on all womenThe participation in the study validated the pregnancyStaff felt more open to discuss the loss in the follow up clinic (Change appointments PP Clinic visit)Registry to report loss >20 weeks /500gramsPRE-TWENTY WEEK LOSS AND GRIEFPRE-TWENTY WEEK LOSS AND GRIEFCraven,D.,&Wise,L.A.(2000). The epidemiology of recurrent pregnancy loss. Seminars in Reproductive Medicine,18,331-339

Ventura,S,.Mosher,W., Curtain,S., Abma,J., &Henshaw,S.(1999) Highlights of Trends in Pregnancies and Pregnancies Rates by Outcome: Estimates of the United States, 1976-96. National Vital Statistics Reports; 47(29)

ReferencesReferencesPRE-TWENTY WEEK LOSS AND GRIEFWEB SITES FOR SUPPORTA Place to Remember Babyloss.com (U.K.) Brief Encounters Born Still but Still Born Center for Loss in Multiple Birth, Inc. The Compassionate Friends Gentle Birth (loss resources from a midwifery perspective) Hygeia Foundation & Institute for Perinatal Loss and Bereavement Infants Remembered in Silence M.E.N.D. (Mommies Enduring Neonatal Death) MISS Foundation Pregnancy.org: Dealing with Childbearing Complications Pregnancy and Infant Loss.org Pregnancy Loss and Infant Death Alliance SANDS Stillbirth and Neonatal Death Society (Australia) SANDS Stillbirth and Neonatal Death Society (England) SHARE Pregnancy and Infant Loss Support StorkNet: Pregnancy/Infant Loss

PRE-TWENTY WEEK LOSS AND GRIEFQUESTIONS